SNFData - 205162 - 12/2016 - Worksheet S-3 Part V

EVERGREEN MANOR INC
SACO, ME 04072

Medicare Provider Number: 205162

Cost report status: Settled Without Audit

[Record Code 1174606 - 2010]

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SNF REPORTING OF DIRECT CARE EXPENDITURES				Provider CCN: 205162	PERIOD: FROM 01/01/2016 TO 12/31/2016	WORKSHEET S-3 PART V
OCCUPATIONAL CATEGORY		Amount Reported	Fringe Benefits	Adjusted Salaries (col. 1 + col. 2)	Paid Hours Related to Salary in col. 3	Average Hourly Wage (col. 3 ÷ col. 4)
OCCUPATIONAL CATEGORY		1	2	3	4	5
Direct Salaries
	Nursing Occupations
1	Registered Nurses (RNs)	###	###	###	###	###	1
2	Licensed Practical Nurses (LPNs)	###	###	###	###	###	2
3	Certified Nursing Assistants/Nursing Assistants/Aides	###	###	###	###	###	3
4	Total Nursing (sum of lines 1 through 3)	###	###	###	###	###	4
5	Physical Therapists	###	###	###	###	###	5
6	Physical Therapy Assistants						6
7	Physical Therapy Aides						7
8	Occupational Therapists	###	###	###	###	###	8
9	Occupational Therapy Assistants						9
10	Occupational Therapy Aides						10
11	Speech Therapists	###	###	###	###	###	11
12	Respiratory Therapists						12
13	Other Medical Staff						13
Contract Labor
	Nursing Occupations
14	Registered Nurses (RNs)						14
15	Licensed Practical Nurses (LPNs)						15
16	Certified Nursing Assistants/Nursing Assistants/Aides						16
17	Total Nursing (sum of lines 14 through 16)						17
18	Physical Therapists						18
19	Physical Therapy Assistants						19
20	Physical Therapy Aides						20
21	Occupational Therapists						21
22	Occupational Therapy Assistants						22
23	Occupational Therapy Aides						23
24	Speech Therapists						24
25	Respiratory Therapists						25
26	Other Medical Staff						26

FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4105.4)

08-16						Rev. 7